THE PATHOGENESIS OF NIDDM

Improvements in the specificity and sensitivity of assays for insulin-related molecules in the circulation have proved to be necessary and informative in studies of the pathogenesis of non-insulin-dependent diabetes (NIDDM). Of particular interest has been the close relationship between increases in des 31,32 split proinsulin and susceptibility to loss of glucose tolerance and the insulin resistance syndrome. It is suggested that the analogy can be drawn between this measurement and the measurement of HbA(1c). The amount of this partially processed precursor of insulin in the circulation indicates the degree of glucose stimulus applied to the beta cell combined with the inherent capacity of the insulin secretory system to respond. Further improvements of the sensitivity and specificity of the assay of proinsulin related molecules are desirable. Deterioration of the early insulin response to oral glucose is a major feature of the loss of glucose tolerance associated with the transition from normal to impaired glucose tolerance and to NIDDM. The extent to which this loss of insulin secretion reflects a major predisposing factor in the aetiology of this type of diabetes or is secondary to glucose toxicity or amyloid accumulation remains to be determined. A relationship between birth weight and impaired glucose tolerance, NIDDM and the insulin resistance syndrome has now been observed in two populations in the UK, in Mexican Americans and in Pima Indians. It is therefore reproducible and applicable to widely differing populations. Much further research is indicated to determine, amongst many questions, how much diabetes is associated with this link and what factors explain it.